E. F. Yates1, S. T. Hawley1, A. M. Morris1 1University Of Michigan,Ann Arbor, MI, USA
Introduction: Coordination of care has been identified as a priority by the United States Institute of Medicine and is frequently cited as an area for improvement in surgical care. Despite the wide recognition of this deficiency, little is known about the effectiveness of interventions specifically targeting care coordination in the surgical setting.
Methods: We performed a systematic review of published literature from 2000-2016 adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with key words indicating surgical care and [“coordination” OR “continuity” OR “surgical home”], in the Central, CINAHL, EMBASE, Ovid and Scopus online databases. Exclusion criteria were non-English language, non-U.S. health care system, patients <18 years, absence of primary or secondary data, absence of an intervention to improve coordination of care with evaluation of outcomes. Identified papers were screened by abstract for exclusion. Remaining articles were independently reviewed by two investigators using a data abstraction tool to assess eligibility, purpose, design, results, conclusion and study quality. Studies were discussed to consensus.
Results: The initial search identified 1870 potential articles, of which 26 were duplicates. Abstract screening yielded 165 articles for full review. Among these, 24 were appropriate for inclusion in the final evaluation.
Coordination of care was referred to but never explicitly defined in any article. All interventions were tailored to institution or system specific challenges, and consisted of planning sessions (e.g. value stream mapping), e-tools linked to electronic medical records, interpersonal communication tools, assignation of personal responsibility, and interdisciplinary use of midlevel providers. Interventions were deployed in 5 setting types: outpatient clinics (n=2), operating rooms (n=2), in-hospital patient hand-offs (n=2), in-hospital perioperative care (n=16), and transitions to outpatient management (n=2). Measured outcomes included clinical outcomes (n=17), cost/resource savings and timeliness (n=9), and staff perceptions (n=7). Several studies measured outcomes in multiple categories. Clinical outcomes included symptom resolution, mortality and complication rates, and satisfaction with care. Staff perceptions addressed a wide variety of issues ranging from perceived safety climate to perceived patient education. Overall methodological rigor was low; 25% of quantitative studies failed to use any statistical tests and all mixed or qualitative studies had an absent or insufficient methodology.
Conclusion: In spite of the widely acknowledged critical importance of improving coordination of care in U.S. surgical settings, it remains inconsistently defined and studied. Agreement regarding fundamental concepts and standardization of relevant measures could potentially improve coordination, which is applicable to all facets of quality in surgical care.